28 August 2008

Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

"So, there you have it. Voila! Problem solved."

I see -- if we stop counting the uninsured, that means we don't have any. And the government pays! I did not know that. When do I get my check for the last eight years' worth of uncompensated care I delivered?

Seriously, it is comments like this that reveal the complete lack of understanding -- and interest -- in real health care coming from the modern republican party. It's like they take pride in being ignorant! With advisors like this, it is no surprise that McCain's health care plan contains exactly nothing to help alleviate the crisis in health care, and would very likely increase the number of uninsured Americans. I expect that is why he doesn't want to count them any more.

25 August 2008

I don't know that there are many (any?) ED directors or practice managers that read this blog, but if there are some ER docs reading, there is a good chance that there are some future ED directors reading this, and one part of the job is negotiating and maintaining the contract with your hospital clients. I'll throw out a quick disclaimer here: I'm not a lawyer and do not purport to have detailed knowledge of contract law. I can speak from some experience and from my own knowledge base, and take of that what you will. Make sure you have good counsel when contracting.

Care and Feeding While in this PC era we refer to our patients as "customers" or "clients," from a business perspective the hospital is the ED physician's client. They are the ones who are providing you with access to your patients and the revenue they represent, and they have the ability to replace you with another vendor, should they choose. Unless your practice is in a particularly distressed market, the chances are that there are a dozen contract management groups (CMGs) out there that would love to have your contract. So you need to pay attention to your contract as your group's fundamental and irreplaceable asset. A lamentable tendency of physicians is to view and treat the hospital administrators as adversaries, especially when the "suits" are non-physicians. It is true that some administrators are clueless or hostile, and in those cases you have to play the hand you've been dealt. The key to contract security is to cultivate the relationship between your group's leadership and the key decision-makers in your hospital. To neglect this relationship and to neglect the key concerns of your administration is to allow an opening for another entity to come in and steal your contract. It may seem unlikely, but most hospital administrators get cold-called by contract management groups on a regular basis. Don't give them any interest in taking that call. Know your administrator's concerns, know where their interest is focused, and make sure that you align your group's interests with theirs.

Term and termination How long should the contract be good for? Do you want an "evergreen contract" which will renew automatically every year until someone wants to modify it? It's low-maintenance, which is nice, and if there are no items of value to be renegotiated then there's no pressing need to renew it periodically. Personally, I do not recommend this approach. I like to schedule some "face time" with our hospital leadership every so often, to discuss the "relationship" and make sure that they are happy with the services we are providing. Also, if you have an evergreen contract which has been unchanged for a number of years, and you want to modify it, it's kind of a big deal and your administrators might view this negatively. There's more flexibility in a contract that you renew annually or bi-annually. Termination will usually be 90 or 180 days notice, more if the contract is terminated without cause. "Cause" should be clearly defined and limited to Very Bad Things, like loss of malpractice insurance or Medicare eligibility. Ideally, the termination notice should be on the longer side; this makes it a bit harder for the hospital to replace you, and if they are flirting with a CMG you have more time to respond and remedy the situation.

NoncompetitionIt is common and reasonable for the hospital to ask its partners not to compete too directly with their business, but the restrictions should be limited and justifiable. For example, many contracts will prohibit the ED group from opening an urgent care center or "boutique" ER within a certain geographic radius from the facility. I've always viewed this as fair. But the contract should not prevent you from acquiring other hospital contracts, should the opportunity present itself.

LiabilityThe hospital will typically require you to maintain professional liability insurance, which is something of a no-brainer. But pay attention to the details. Are you required to maintain certain limits? This will depend greatly on your market. $1/3 million is common, $2/6 million is high-end. Whatever the requirement is, make sure it is consistent with insurance that is actually available in your market, and that you actually have the stipulated insurance. It is also helpful to compare the limits you are required to hold with other members of the medical staff -- EM is more comparable in risk to ortho or GYN-surg than it is to OB or Neurosurg, and you should not be held to a higher standard than similar specialties. Also, some hospitals will insist on A-rated insurance, which may not be reasonable in certain markets or with certain products like risk retention groups. Some older contracts still contain "mutual indemnification" clauses, which are bad things and should be stricken. If there should happen to be a judgment in excess of policy limits and the hospital has to pay the balance, they can use this clause to come after your group for restitution. However, there is no balancing risk for the hospital; it's a very one-sided clause which is disadvantageous to the ER docs. Also, should the ED medical director ever be sued for his actions as medical director, the contract should specify that the hospital's general liability or D&O policy will cover him.

Other Items of Value ED Medical Director: The ED Medical Director is a facility function and as such the salary should be covered at least in part by the hospital The proportion paid by the hospital might be determined by the time required by the job, if it is less than full-time or if the director spends much time on other activities. The contract should also specify the process by which the director is chosen (ideally a collaborative process in which both parties have input), who the Medical Director reports to (to ensure he has adequate institutional clout), and the degree to which the Medical Director has budgetary authority (also important in terms of clout).Subsidies: Direct subsidies are nice if you can get them. They are, however, problematic under the Stark regulations, unless you are in a distressed market and are willing to jump through some hoops. My experience is that subsidies are becoming less and less common, and they certainly are a liability when it comes to renewing and protecting your contract. Incentive compensation: if your practice is in need of additional monies to ensure adequate compensation for your docs, and the hospital is unable or unwilling to give free cash, incentives are permissible and a creative way to increase your bottom line while positioning yourself as a good partner for the facility. Find out what it is that your CEO values -- whether it's patient sat, LWBS, JCAHCO core measures, CMS P4P or whatever, and as long as it can be affected by your department and measured, offer to make this a performance bonus clause in your contract.Billing and coding: Who will perform it? If the hospital does, how will you be paid? Based on actual collections or a predetermined fraction of billed charges? Hospital coders and billing offices tend not to be aggressive on the professional side; the amounts are too small for them to care about. Basically they give away the doctors' services, and their profit center is the facility charge. So you should not accept actual collections, and you should ensure that you have input and control over the coding process to ensure that all professional charges are captured accurately. In most cases it is better for the docs to accept the cost & risk of self-billing. Unless you had a large subsidy from the facility, generally the entrepreneurial spirit will ensure that your group will do better managing its own revenue cycle. If you are going to self-bill, make sure that your billing vendor is given adequate access to records and hospital space as needed.Physician Fee Schedule: Hospitals do not want their docs gouging the community, as this leads to complaints, so some will try to restrict your ability to set your prices. Usually as long as you can justify your fee schedule as reasonable, this should not be a contentious issue, but be sure that you have the freedom to adjust the fees as needed. We use the Ingenix database, and I have always felt that somewhere above the 50th percentile but below the 75th strikes a nice balance between aggressive pricing and gouging.Medicare and Medicaid: You will be required to participate. Get over it.Managed care and payer contracting: This is highly market dependent. Generally, you need to have the freedom to negotiate with payers, and the only credible leverage ER docs have is to go non-participating with a plan. Therefore, if your hospital requires you to participate in every plan they do, then you have zero leverage and will certainly have to settle for crummy compensation. This is worth fighting for, in most states. Of course, the freedom to go non-par needs to be used very judiciously and selectively, as the political ramifications are significant. Often times you can mollify the hospital's concerns with a clause that requires the ED group to negotiate in good faith to participate in all the plans the facility does.Charity care: In my opinion, this is an opportunity to put on the white hat and offer to take a loss for the home team. Most services which appear to be charity are going to be non-recoverable, and the hassle and complaints that go with aggressive collections may not be worth it. You can offer to write off cases based on certain parameters (or mirror the hospital's charity policy) and you'll look like a good team player. If you choose, you can ask for some reimbursement from the hospital for your largess.

OperationsProvider Qualifications: At a minimum, the contrast will have some boilerplate regarding the duty of the ED group to provide licensed docs with valid DEA numbers, medicare eligible, etc. Some hospitals will choose to place certain extra minimum qualification levels on their ED group -- Board Certified/Board Eligible, Residency trained vs grandfathered, for example. My view is that these issues are more properly a function of the medical staff process, but depending on the composition of your group and your hiring philosophy, you may choose to accept this clause to show your facility that you are committed to maintaining standards.Exclusivity: This can be a helpful perquisite in certain circumstances. Exclusivity means that your group will be the sole provider of care in your ED, and this really establishes the ED as your turf. It precludes private attendings and specialists from bringing in their own patients and seeing them in your department. An exclusivity clause may not be needed if your medical staff does not do this very often or if they do so in a non-disruptive manner. However, if patients often come in to see "their" doctor, and if this gums up patient flow, or if the privates are less-than-prompt in coming in, then you may benefit from exclusivity. Be prepared for pushback from the medical staff if you go there; this means lay the groundwork in advance to ensure that the suits are on your side, and make sure you have some leverage or bargaining position to propel you to a win, before you initiate the discussion.Out-of-ED responsibilities: Does your group cover in-house codes? If so, the requirement to do so should be spelled out in the contract. If this responsibility would leave the ED uncovered for any significant time, you may wish to have the facility indemnify you against any adverse event that resulted from this dual responsibility.Staffing level or on-call requirements: Ideally, the staffing level for the ED should be set by the ED director and nurse managers. The contract should not be excessively restrictive in requiring a high level of staffing, or at least no higher than what you are willing to actually provide! On-call requirements are becoming more popular as hospital administrators get more savvy about "surge capacity," but again, you will have the most flexibility if you can keep this out of the contract.

LegalitiesWho owns the contract? Ideally, the contract is between your corporation and the hospital. However, in many cases, the contract may be between one or a few select managing partners and the hospital. If you're not one of them, you're out of the loop and out of control. By definition, there's not much to do about it until you are in a position to take over the contract (with or without the assent of the current contract-holders). One caveat: having a single contract-holder is not great for contract stability. Should that individual die or abruptly decide to get out of the game, there's no assurance that he or she will pass the contract back to the group. It may be sold to another favored friend, or to a CMG. While it may not fall into the purview of the facility contract, some sort of "succession planning" might be prudent to ensure continuity of your practice.Compliance: though your group is elsewhere obligated to be in compliance with the alphabet soup of applicable federal regulations, they will likely be reiterated here. Just be aware that in the event you are found to be noncompliant in any respect (most notably billing practices) this may give the hospital a club to use against you. While you cannot escape the obligation to remain compliant, make sure that the hospital must give you an opportunity to remedy any and all compliance deficiencies prior to taking any action against your group. Dispute resolution: Binding arbitration is a very good idea, as it is cheaper, easier, and much much faster than litigation, so it's a good idea to have a dispute-resolution process that includes arbitration. Mandatory mediation is, in my opinion, less useful but not unreasonable. However, the point does remain that if you do have a serious enough dispute with the facility that it requires arbitration, your contract is probably toast anyways.Recitals and boilerplate: There's a lot of legalese in these contracts "Whereas Hospital owns and operates a licensed general acute care hospital and is in need of physicians to provide professional services to patients of the Department, and Whereas Medical Group is a professional corporation engaged in the private practice of medicine... blah blah blah" and it can be really dense and boring. READ IT ALL, and make sure that the words do reflect the reality.

OK, that was a long and boring post. It's an important topic, however, and if any of you made it all the way to the bottom and are reading these words, I hope you found it helpful. Now, I have to quit blogging and get back to real work. Anyone want to guess what I am working on this week?

23 August 2008

Biden, eh? Not terribly surprising -- a safe pick, but I was hoping for someone a little more unconventional. I can live with Biden. He's a reliable liberal (maybe more centrist than I would like), well-spoken, and a solid campaigner. He has the gravitas thing, and unimpeachable national security credentials, something which the GOP will portray as a weakness, but certainly makes the ticket stronger. It also boxes McCain in a bit on his VP pick. A lightweight pick with little experience (Jindal, e.g.) would probably get chewed up in the debates (as Edwards was in 2004). Which is the other thing I like about Biden. He's an unapologetic partisan attack dog with a gift for the sound bite. (He coined the Guiliani "Noun, verb, 9/11" slam.) If Obama can't or chooses not to after the jugular in his rhetoric, Biden will do so for him. By picking such a bulldog as his VP, Obama is signalling that he intends to aggressively engage the right wing on seriously policy issues and national security, and to win them. The democrats' defensive crouch is finally over.

The one complaint I might have the the ticket is not exactly euphonious. "Obama-Biden"? Too many "b"s too close to each other. "Clinton-Gore" and "Bush-Cheney" sounded great, punchy, memorable. "Obama-Biden" doesn't quite roll off the tongue quite the same way, does it? The new logo, however, looks pretty good:McCain called Biden to congratulate him and let him know he'd get back to him real soon with his debating partner.

22 August 2008

I previously blogged about the most common reasons patients come to visit our ER. I was browsing the National Health Statistics Report (what? doesn't everybody?) and the federally-sanctioned list of most common complaints caught my eye.

Bear in mind that 1% equates to about 1.3 million ER visits for that complaint.

So I dragged my sorry ass out of bed at 0445, showered, dressed, skimmed the news, and left for work at 0530. I walked into work at 0600 carrying my cup of coffee. I hate the early shift.

A dozen pairs of eyes stared at me in surprise when I walked in. "What're you doing here?""Um, I'm here for my shift.""No, Dr Johnson is here for the 6AM shift." Dr Johnson smiled at me as he picked up a chart."That can't be right. I double-checked my schedule, and I am sure I'm on at 6.""Well, our schedule says it's Dr Johnson.""You've gotta be kidding me." Damn. I checked, and they were right.

21 August 2008

One almost wonders if it's self-mockery: McCain's gaffe regarding his lifestyle of the rich, famous, and forgetful shouldn't count, according to his campaign because -- are you ready for it -- he was a POW! His invocation of his POW status is quickly approaching the level of Rudy's 9/11 shtick.

Sen. John McCain (R-Ariz.) said in an interview Wednesday that he was uncertain how many houses he and his wife, Cindy, own.

"I think — I'll have my staff get to you," McCain told Politico in Las Cruces, N.M. "It's condominiums where — I'll have them get to you."

The correct answer is at least four, located in Arizona, California and Virginia, according to his staff. Newsweek estimated this summer that the couple owns at least seven properties.

Obama doesn't wait to make this an issue:

I like this ad: it's truthful and likely to resonate well in this time of housing and mortgage insecurity. I'm glad to finally see someone making the point that the guy who owns eleven homes, wears $520 shoes, flies around in a private jet, and thinks that under $5 million is not rich is the one who's the real elitist in this race. I also like the tag line about the one more house we can't let McCain have.

This is also a rather cautious ad. Some counts put McCain's total as high as eleven (here's a nice rundown), but I suspect that Obama didn't want to fall into a gotcha trap, so they went with the easily provable number of seven. I think Ygelsias had the funniest take on it:

[There] is one reason why it’s a bit unfair to tag McCain as out of touch for being unable to remember how many homes he owns. When one of your homes is really a combination of two different luxury condos the metaphysical status of your property comes into question. You’d really need to ask a trained professional mereologist to resolve the issue and can’t expect McCain to speak to it personally.

20 August 2008

I found The Body Bakery linked through Crazy Andy, and it's genuinely disturbing. These incredibly realistic sculptures of dismembered human body parts are all made out of bread, edible, packaged like food, and sold for consumption in the artist's gallery in Thailand.

19 August 2008

You know you're in trouble when you call poison control and the attending toxicologist just laughs and laughs at your consult. I don't mean a little snicker, but a full-throated guffaw, lasting thirty seconds, followed by, "Seriously? You're not shitting me? I've been doing this 25 years and even I've never heard of that one!"

The case was, I must admit, unique.

The patient was a 22-year old man with a known history of schizophrenia, who had been admitted to the hospital for a soft-tissue infection which had subsequently developed into CA-MRSA osteomyelitis, an infection of the bone. This required long-term IV antibiotic therapy, so the patient had a PICC line inserted. I'll give the hospitalist team credit -- they considered the wisdom of sending a mentally ill person home with an indwelling venous catheter, even to the point of having an inpatient psychiatry consult regarding that issue. The big risk is generally that patients might inject heroin or other illicit substances into their line, or that they will not keep it clean and they will develop line sepsis. However, the patient had never been known to abuse drugs, and his delusions seemed well-controlled on his medications, so it was ultimately decided to be safe. They arranged close home health support and frequent checks with his case manager and home he went for six weeks of IV antibiotics.

Somewhere around week four, he quietly began getting more delusional. The thought of having an infection in his bones seemed so dirty, so impure. He spent more and more time dwelling on how filthy and repugnant he was inside. He wanted to cleanse himself, to undergo a purification, a catharsis. The antibiotics clearly weren't working, because he still felt unclean, tainted. So he started casting about, looking for something he could do to quickly eradicate the pollution from his bones. What could he use to get rid of this contamination?

So he consulted Google: what kills germs best? The answer:Yes, bleach. Good old household, undiluted 5.5% sodium hypochlorite. It kills all germs, doesn't it? That'll fix what ails me, he figured, and proceeded to draw up 40cc of bleach into syringes and inject it into his central line.

The home health aide came over shortly to get his daily antibiotics started, but the patient cheerfully and proudly informed her that he wouldn't be needing any more antibiotics, because he had cured himself. I can only imagine her reaction when he told her how.

Thus he came to me.

As I mentioned above, poison control was not exactly helpful to me. He thought it was hysterical, but could give no meaningful guidance. A lit search was more or less fruitless as well. I had a feeling that he would be fine: many suicidal patients try to kill themselves by drinking bleach, but wind up disappointed at what a benign and well-tolerated substance it is. So we worked him up.

We had the hardest getting labs on him. The lab techs reported that when they tried to spin his blood down, they couldn't -- it had just turned to a gelatinous goo in the tubes. The bedside chemistry machine reported more or less normal electrolytes, but the tea-colored urine coming out of his foley catheter looked ominous.

Eventually I was able to calm the toxicologist down enough to rationally discuss the case. We figured that the bleach probably would have been pretty rapidly diluted when injected directly into the central circulation (I still somehow can't believe I'm typing those words), so the likelihood of end-organ injury was probably low. But the portion of the blood that was exposed to the higher concentration bleach probably would hemolyze, spilling hemoglobin into the extravascular space.

So we could think of this as resembling rhabdomyolysis, with elevated myoglobin levels, or, more aptly, like blackwater fever. We hydrated the hell out of him, since hemoglobin is very toxic to the kidneys, monitored his potassium, renal function and blood pressure, and admitted him.

I'm pleased to say that he did fine. Full recovery, and off to a med-psych facility within forty-eight hours.

And now I've got a great case to write up if I ever feel like getting published. (I suspect I'm too lazy.)

My shift: ER under construction, patients stacked three-deep in the hall, no free computers to use, all of my patients staffed by the "very special" nurses, average patient age of 83, percent requiring rectal exams 100%.

About three hours into the shift, I had a sudden pain in my head, left frontal area. I found myself hoping: "Hey, maybe it's a subarachnoid. Then I wouldn't have to work the rest of the shift."

Sadly, the headache soon passed. But the pain continued for seven more hours.

18 August 2008

It was a new surgeon on call; I had not spoken with her before, but she seemed nice enough. I greeted her with the following bit of sparkling wit: "They say a pathognomonic sign of appendicitis is when the ER doctor can find the appendix on the CT scan without assistance. Well, I'm looking at an abdominal CT right now and I can see the appendix." She laughed and said she'd be happy to come right down. I think I'll get along with her fine. And yet again I amuse the heck out of myself.

You may recall a month or so ago, there was what was described as a minor incident, when Obama's campaign plane made an unscheduled landing in St Louis, for what was described as a minor incident: the aft inflatable emergency exit slide deployed in the tail cone. This was described as not an emergency and not an incident affecting the safety of the flight.

[The pilot] no longer had full control of the plane's up and down movements, [and] told an FAA air traffic controller "at this time we would like to declare an emergency and also have CFR [crash equipment] standing by. ... Be advised we have Senator Obama on board the aircraft."

Now this was an MD-81, essentially the same plane as Alaska Air Flight 261, which also had pitch control issues and wound up plunging into the Pacific Ocean. Although in that case the loss of control was due to a different cause, a broken jackscrew, the symptom experienced in the air was the same. With that history in mind, how much must those pilots have been crapping in their pants? Still, the problem was resolved and they did land safely, and Obama's new ride is a more modern and safer 757, so all is well.

Except that my next flight to Chicago is scheduled to be on the same type of plane. I hate the MD-80's and 90's. They're small and cramped and loud, old, dingy and, it would appear, unsafe. I can't wait till the major carriers retire them all.

14 August 2008

Hungarian weightlifter Janos Baranyai dislocated his elbow in Bejing, competing in the snatch, while lifting 148 kg (326 lbs) over his head:More pics (some quite disturbing) visible here, at the Daily Mail. (where else?) What a terrible way to end your Olympics. I feel awful for him.

I've seen lots of dislocated elbows over the years -- in fact, I reduced an elbow just Tuesday. That was dislocated in the more traditional mechanism, a fall from a bicycle, on outstretched hand. I can't recall ever seeing a mechanism of injury like this one. Generally, the radiographic image of a (posteriorly) dislocated elbow will look like this:

There may be associated fractures of the coronoid process or the radial head. Reduction is fairly simple -- after adequate analgesia and sedation (if you're feeling nice), you sit the patient up (as much as possible), with the elbow flexed at about 90 degrees (which is where the patient will likely be holding the arm). You hold the patient's wrist with your ipsilateral hand, and place your contralateral hand on the antecubital part of the forearm, slowly applying downwards traction. As you feel the biceps relaxing, you gently extend, then fully flex the elbow. You may need to have an assitant push the olecranon anteriorly. A definite "clunk" will indicate a positive reduction, and you should immediately be able to take the joint through a full range of motion with little to no resistance. The really challenging part of reducing the joint is overcoming the obligate spasm of the biceps and triceps -- something which I imagine would be even more difficult in a patient capable of lifting 328 pounds over his head! Someone so muscular might even require general anesthesia and neuromuscular paralysis to reduce, I expect.

Recovery is pretty good, but I suspect that Mr. Baranya's weightlifting career may be over -- once those ligaments have been disrupted, they never recover their full strength, and for such a high-intensity sport, it's hard to see performing at a world-class level on a less-than-intact elbow.

11 August 2008

There are a lot of ignorant, narrow-minded, uninformed and just plain stupid people who will tell you that the Beijing Opera is weird and boring. I agree with these people.

The biggest problem for me was the pacing. I'm used to American action movies, which routinely feature shootings, stabbings, sex scenes, car chases, helicopter crashes, nuclear explosions and at least one beheading before the opening title. Whereas in the Beijing Opera, it can take a performer as long as eight minutes to convey an idea such as, ``Well, here I am!''

The performer conveys this by moving slowly around the stage making traditional mime-style motions to the accompaniment of an orchestra playing traditional Chinese instruments that sound, to the ignorant Western ear, like an untuned piano being attacked by beavers. Every so often the orchestra makes a loud noise that sounds like, quote, ''SPROING,'' and at that instant the performer suddenly stops and stares directly at the audience with an expression of what appears to be astonishment, as if to say, ``Wow! You are still here!''

This is a brute-force political tactic by the insurer's lobby to impose de facto price controls on the health care market for ER services. Typically, ER doctors contract with HMOs or insurers in a free-market arrangement to agree on a fixed price for services to ER patients, usually at a substantial discount from the out-of network rate. In these cases, the insurer pays the bulk of the ER doctor's fee, and the patient is only responsible for their co-pay. However, if the HMO does not offer adequate compensation, the ER docs may opt not to contract, becoming "out of network" physicians, and in that case the patient is responsible for the balance of the ER doctor's fee after whatever arbitrary amount the insurer pays.

This makes patients unhappy, and their complaints often spur the HMO and the doctors to come to agreement on terms of reimbursement for services, usually at somewhat better rates for the physicians.

What is going on now is that if the HMOs are successful in outlawing balance billing, physicians will have no recourse but to accept whatever pittance the HMOs offer, and there will be no brake on decreasing reimbursement to ER doctors. Given declining compensation from Medicare and Medicaid, this will put greater and greater economic pressure on ER docs in California. I'm appalled but not surprised that the Republicans in Sacramento are willing to sell out their nominal allies, the physicians, to benefit the insurance industry -- the CA GOP is highly pro-corporate. Kudos to CAMA and CA-ACEP for stepping up to fight these regulations, but I fear the deck is stacked against them.

And I would like to reiterate a warning to all those conservative medbloggers out there who fear universal health care in favor of our current "free market" based system -- there is very little that is free market in health care as it is, and with the insurer's lobby ascendant that will shrink further. Many complain that a single-payer system is equivalent to slavery because it compels physicians' work product while denying them fair payment for their labor. What then is this? Medicare for all would be preferable, in fact, because there would be transparency and accountability (through the ballot box). But if the insurers are allowed to run roughshod over health care providers, they are accountable to nobody and need reveal their business practices to nobody.

If you live and practice in California, or if you live in California and worry about having to visit your understaffed and overcrowded ER, a call to your state legislator might just be in order.

Hey, everybody, I'm back from my blissful vacation, and feeling more refreshed than I have in years. Thanks for enduring my crappy reruns classic posts, and I will get cracking on bringing you some regular crappy new posts exciting new content!

On another note, the magic of sitemeter tells me that I am now at 300,000 visits to my little blog. What an amazing milestone. I started this blog quite accidentally, and never envisioned it as anything more than a little hobby and a creative outlet. That so many of you have taken the time to stop by and read it, that apparently you have found something valuable or entertaining in my musings, is profoundly validating and also humbling, and I thank you for it.

10 August 2008

I drive too fast. It’s a bad habit I have, and I am unapologetic about it. At least I could say that until recently, I had never bent sheet metal. (And that event occurred at less than ten miles per hour!) As a result, I have had many opportunities to discuss the various nuances of the traffic statues with law enforcement authorities by the roadside. One of the perks of my profession is that the police tend to take a lenient view of my infractions, especially if I was traveling to or from work. We work together a lot in the ER, and that does buy you some license (deserved or not). For example, we see a lot of patients brought in by the police for a “pre-incarceration medical screening exam,” or what the nurses call an “okey-dokey for the pokey.” And we make sure to give them special service – in and out, no waiting.

So I was pretty chapped not too long ago when I actually got a speeding ticket. I was tired and not paying attention after working a night shift, but I can’t complain – it was 76 in a 60. The conversation went like this:

“Hi, I’m Trooper Jones with the State Patrol. Do you know how fast you were going?”“Well, sir, I’m not sure there’s a right answer to that question.”(Taking in my scrubs and stethoscope around my neck) “Are you going to work?”“No, sir, I’m on my way home. I was the overnight doctor in the ER at The Big Hospital.”“Ah, I see. May I have your license and registration?”

And so on. I was annoyed, but busted fair and square.

But then, two days later, around midnight, who should come into The Big Hospital with an “OK to book” but Trooper Jones! I saw him and said hi; he didn’t recognize me at first. “Remember?” I prompted, “Saturday morning on the trestle, 76 in a 60?” His face went white. He remembered.

But I am a consummate professional, and also not a complete dickhead, so I was resolved to get the trooper back out on the street ASAP. Also, I wanted to get my revenge by being extra nice and service-oriented, to make the cop feel guilty for ticketing me. But I was busy with a couple of actually sick patients, so I ordered an x-ray on the prisoner and made a mental note to get back to them shortly. As it happened, my partner (we are double-covered overnight) signed up for the patient in the interim, so I figured I was off the hook. Oh well.

Three hours later, I walked past the room and noticed the trooper sitting there with a forlorn look.

“What on Earth are you still doing here?” I asked, stunned.“I don’t know,” replied the trooper. “They came and took an x-ray and never came back.”

I went to my partner. “Bill, what are you doing with the trooper in room 8? He’s been waiting forever!”“What trooper?” Says he. “There was one in room 7, hours ago, but they left.”“No, Bill, they’re in 8, and still waiting!”“Oh, shit!”

So Bill rectifies his error and gets them promptly discharged, belatedly. On his way out, the trooper approaches a nurse he knew socially: “Did I have to wait three hours because I gave that doctor a speeding ticket?” She explained what he really happened, and I am glad, because I would not have wanted him to think I was so petty and vindictive.

09 August 2008

I writing you in response to your letter of the tenth. I understand that you do not feel that you should have to pay the ER doctor's bill for the treatment you received in the ER, since you were sent over to the ER from your doctor's office for a "direct admission."

However, it appears that there is some confusion over this point. If your doctor wanted you to be a "direct admission," he (or she) would have sent you to the hospital admitting office with orders to have you admitted under his or her own name, or under the care of the on-duty hospitalist. He did not, but rather sent you to the ER.

It is possible that he sent you to the ER because the on-duty hospitalist refused to accept you as a direct admission, feeling that you needed urgent assessment and stabilization treatment in the ER. Is is equally possible that your doctor sent you to the ER because it was the easiest way for him to get you off his back and pass the buck to another doctor. It is possible that he simply forgot how to arrange a "direct admission" because "just go to the ER" is a million times more common these days. We will never know because a review of the ER phone log reveals that he did not call with any instructions for the ER doctors regarding the expectations for your ER visit. Since you arrived to the ER after the close of office hours, your doctor was not available by phone to verify the plan, and the on-call clinic doctor did not know who you were.

A review of the ER record shows that you did receive a full history and physical exam, and that the ER doctor who saw you performed and interpreted multiple diagnostic tests, reviewed your medical records, treated you with intravenous medications, and consulted with specialists before making the independent decision to admit you to the hospital. We feel that the ER doctor's investment of time and effort (and risk) into your care justifies the charges applied to your account.

I know it does not feel like the ER doctor "did" anything because most of the work took place out of your sight, and because you had already told him that you were there to be admitted. However, most patients sent to the ER under similar circumstances in fact are sent home, either because they turn out to not have a medical problem requiring admission, or because their illness can be diagnosed in the ER and treated as an outpatient. So, in fact, the ER doctor did provide a valuable addition to your care.

We apologize for any annoyance or irritation you have suffered, and hope this writing finds you in good health. Please remit payment at your earliest convenience.

Regards,

Shadowfax, MD

cc: Primary Care MD

(Addendum: In fairness, I often do reach the PCP by phone who informs me that he did not send the patient to the ER to be admitted, but to be assessed. Somehow patients reliably misinterpret being sent to the hospital as implicitly meaning 'for admission.")

"Now this may hurt a little . . . actually it's going to hurt rather a lot."

For patients with a medical diagnosis:

"There's Good News and Bad News. The Bad news is you have [X]. The Good news is that it's you and not me."

"Everybody's got to die sometime."

Now, I've never said (most) anything on this list, but I have a wicked mind and have thought about it on many occasion. I'm sure you have thought about it, too. Feel free to add suggestions in the comments.

07 August 2008

We settled two lawsuits this quarter. In neither had there been medical negligence. It's pretty galling to settle cases like these, but it's smart. The deck is stacked against us, and you have to make the good decisions, even when it is bitter.

Both cases were quite straightforward. In one, there was a DVT diagnosed and treated according to hospital protocol -- low molecular weight heparin and transition to warfarin. The patient went on to have a pulmonary embolus and recovered uneventfully with no adverse sequelae. We only settled because it was cheaper than going to trial. As galling as it was to pay, we did have the satisfaction of knowing that the plaintiff's attorney took a loss on the case. (It was a very small payout, and his preparatory expenses were considerable.)

The other case is more maddening. A very young child was dropped on his head, suffered an epidural hematoma, which was diagnosed on CT, and the child was transferred to a regional trauma center. He recovered, though with some degree of neurologic disability. The plaintiffs waited ten years to file (!) and alleged that some minor delays in CT and transfer were the cause of the bad outcome. This is obviously bogus. But we knew they were going to wheel a brain-damaged kid in front of the jury. The likelihood of losing this case was significant for that reason alone, and the risk of a big payout was significant. So we settled in the mid six figures. I hated to settle, and struggled with the decision, but with juries making decisions, it's a crap shoot, and they consistently rule in favor of sympathetic plaintiffs.

What can we do? When you are at Yellowstone, they tell you not to feed the bears because it just encourages them. But that metaphor doesn't work when the alternative is to let the bear maul you and hope that he won't get all of your food.

The real problem isn't that these suits were frivolous. I don't really know what that word means. I do know they were baseless. The problem is that the newspapers are replete with cases where there is a huge jury award in cases where there was no malpractice. This is what induces us, and lord knows how many other medical groups, to settle cases which were well-handled. When there is no correlation between whether negligence occurred and whether you win or lose, the only viable strategy is to pick your fights very very carefully.

Simply: Lay juries are not qualified to make determination of causation.

What typically happens is that the two sides present dueling expert witnesses who assert fundamentally incompatible standards. The jury is then left to decide which was more credible. How the hell are they supposed to decide which of two eminent, respected academicians is right? When medical experts disagree, how on earth can uneducated laypersons decide accurately what constitutes negligent behavior? If the plaintiff died or was severly imparied as an outcome, that inarguably biases a jury to assume that "something must have gone wrong," and their verdicts do tend to correlate.

I am also aware that the defense prevails in many or most malpractice actions. To me, this is not an indication that the system works. Quite the opposite. There have been cases of which I was personally aware in which the care was clearly substandard but the defense experts were more convincing and the jury went along. The problem is not that doctors win 87% of the time, nor that awards are out of control. The problem is that juries are unpredictable and commonly make very wrong decisions. The result of this is that in many cases patients who were injured go uncompensated (especially if they are not sympathetic victims), and that doctors who were not culpable wind up losing.

When there is not good correlation between causation and verdicts, the system falls apart. I think that tort reform is essential. But I do not particularly favor caps. Caps are clumsy and heavy-handed. Moreover, caps on awards do not get at the heart of the problem, which is the arbitrary and capricious decision-making patterns of juries. It's just as well, because caps are as dead as a doornail, politically speaking. I would like to see an alternative solution. I would prefer special health care courts or some other system which attempts to improve the accuracy of judgements.

06 August 2008

As an ER doc, you are supposed to really live for the bad cases: the crashing patient, shocking the heart, intubating, flinging drugs like an ubermensch, heroically stamping out disease and pulling lives back from the abyss. You're supposed to ride the adrenaline as naturally and instinctively as the surfer rides the wave. Our friend charitydoc perhaps epitomizes this unselfconscious id-like personality that is supposed to be the fundamental characteristic of the ER doc. And truth be told, it's not all myth -- most of us in the ED do get off on the excitement and adrenaline.

But sometimes, you're just not up for it. You're tired, or got in a fight with the wife, or for whatever reason, just can't really summon the enthusiasm for the event. But that doesn't stop them from coming in, does it? Much though you might like to close the doors and turn off the lights, the ambulances still bring you the business. So there's nothing for it but to put on your game face, stand up straight, and head into the room as the paramedics bring in the next customer. It's not too hard, really. After so many years, it's almost a pavlovian response.

So tonight, near the end of my shift, after I had already seen 30 patients in 9 hours, which is unusually busy even for me, the radio crackled to life. The report started a buzz at the nursing station:

Oh, this does not sound good. More details came over: Baby, just a few hours old, umbilical cord still attached. Found in a local pond inside a white plastic garbage bag tied with a knot. Someone who lives on the pond heard some commotion and managed to fish the kid out and call 911.

So we get ready, call NICU, I review the neonatal resuscitation algorithm in my mind as we pull out the warmer and await the medics' arrival. I am not looking forward to this. I can see it now, a cold blue floppy baby. Will they have a line? I can't remember the last umbilical line I started. They probably have an airway already -- the local EMS is very good at that. These are always grim. I wonder in advance how long we will have to go through the motions before we can in decency call it.

To my surprise, the medics come in with a pink, squalling infant. Cold, to be sure, with a rectal temp of 83 degrees. But otherwise fine, with a brand new clamp on the ragged stump of umbilicus, vigorous, and warming up rapidly. Glucose good at 96. The NICU team shows up moments thereafter, and in no time flat, the kid is lined, labbed, x-rayed, and bustled off to the NICU. Babies withstand hypothermia wonderfully; the plastic bag probably prevented drowning and helped the kid float, while the cold water initiated the dive reflex and help put his brain into hibernation. Amazing.

So I wander back out to the near-desolate ED and pick up my stack of incomplete charts. It's funny, sometimes as an ER doc you feel a little cheated when you have a crash case like this that turns out to be a false alarm. You get your game face on for nothing, as it were. But in this case, I feel only relief. Relief that I didn't have to go through the excruciating dance that precedes the formal declaration of a baby's death. Relief that the child is well. Relief that some mother, who in her desperation and fear threw away her newborn baby, is not now a murderer. I wonder if they'll find her? The police have been here and the media have already called. I can't help but feel bad for her, even though she did a monstrous thing. What sort of straits must she be in to try to drown her infant? I cannot imagine.

05 August 2008

Betsy was 85 years old, living independently, and in near-perfect health. Her daughter brought her in when she abruptly became short of breath. I saw her with her three adult daughters at the bedside. She was a bit gray, had labored breathing, with an irregular pulse at 135, and hypoxic. She certainly looked critically ill, but was cheerful and as talkative as the circumstances permitted. Her oldest daughter was a CCU Nurse Supervisor. I went over the differential with her – MI, Pulmonary Embolism, Atrial Fibrillation, Congestive Heart Failure, Pneumonia – and sent off a slew of labs. Her EKG was fast but unexciting, and her chest x-ray was essentially normal. Labs came back unusually quickly, and were unremarkable except for a mildly elevated Troponin, a heart enzyme indicative of a heart attack in progress. Just then the nurse told me that her EKG had changed and that Betsy had developed severe chest pain.

Sure enough, a repeat EKG showed an obvious, massive heart attack in progress, with marked ST elevation. This was actually a good thing, since a) now I knew what was going on, and b) it was treatable. I discussed the options with the family, and they indicated that they wanted the full treatment, so after quick call to the on-call cardiologist, who was dubious but professional, the cardiac cath lab was called in. I wrote the standard orders – morphine, beta-blocker, heparin, etc – and moved on to the next patient in the queue. The Emergency Department was just swamped, with waiting times over three hours. No sooner had I finished examining a young lady with pneumonia than I was paged overhead stat to Betsy’s room.

When I got there, she was dead. Unmistakably so. Her skin was waxen and yellow, and she was not breathing; the monitor reflected a heart rate of 30, but I knew that there would be no pulse if I checked her wrist. It is amazing how obvious it can be when the vital force has departed a body. Taking this in a fraction of a second, I reflexively said “Well, this isn’t good.” Her daughters looked at me with tears in their eyes and the eldest said “We know. We’re okay with it.” I turned off the cardiac monitor and removed the oxygen mask from her face. A few words of condolence and I left them alone. I called the cardiologist back, a bit ruefully, and cancelled the case. We called the chaplain, and I moved on back into the realm of the living.

It’s a bit curious. I’ve always said: “As an ER doctor, most of my patients come in alive and will leave alive no matter what I do; a few come in dead and leave dead. Rarely someone comes in dead and leaves alive, which is a victory, and occasionally someone comes in alive and leaves dead, which I take as a personal offense.” But in this case I wasn’t offended. It was the most natural, wholesome (if there can be such a thing) death I have ever been privileged to witness. It was quick and relatively painless, the whole family was there, and everybody was emotionally in tune with it. I hope I go as well. I’m still kind of shocked at how quick it was. As an ER doc, I see a lot of death, and it’s usually more of a process than an event, and there’s usually a longish time between when it begins and when it is irreversible. Not so with Betsy. There one minute, gone the next.

03 August 2008

Me: (exasperated) You came to the EMERGENCY room at 1AM for a refill on your Viagra?!?

Patient: But it is an emergency.

Me: (incredulous) This is the most trivial, non-urgent thing I have ever seen in the ER. How on earth could it be an emergency?

Patient: (completely impassive) I've got a date tonight.

I didn't have the heart to ask whether his "date" was yet to begin (at 1AM) or whether the girl (?) was waiting in the car. And no, I did not refill his medication, either. I gave him a stern talk abou responsibility and planning ahead and proper use of the ER, scolded him for wasting $200 of the taxpayers' money with such foolishness, and sent him out to his now-joyless date and a follow-up appointment with his Primary Care Physician. Perhaps it was mean of me to deny him the refill, but I work on the same philosophy as the National Park Service: "Don't Feed the Bears."

02 August 2008

You may recall the gentleman who abused his rectum by inserting (or having inserted for him) various items not intended for anal placement. The one identifiable item ws a broken bar glass (note: it was not broken when it was inserted), but the other radio-opague item was more difficult to identify. At laparotomy, the surgeon discovered this:And yes, that is a socket from a wrench set. It was, the surgeon reflected, the largest socket she had ever seen.

No, this is not a picture of the actual item -- it has been lost to posterity, down the biohazard bag, as it should be. The surgeon estimated the item to be at least 1.5-2 inches in diameter.

Sick of the Health Policy and finance stuff? Me too. Here's a nice freakshow case for your enjoyment. You are looking at an x-ray of a man's abdomen. He refused to say what the items in his pelvis were or how they had come to be present there. You can see that the lower one appears to be a glass, perhaps a small tumbler, and that it is broken. He presented to the ER because he was passing blood. I do not know what the other item is -- it does not look like glass. I believe that the gentleman wound up with a diverting colostomy; I have not had a chance to talk to the surgeon who assumed care of this patient. I will post an update when the second item has been positively identified.

01 August 2008

There's a beach in Oregon with my name on it. I'll be back August 10 or so. Never fear -- till then I've got some well-aged, vine-ripened "classic" posts teed up through the magic of blogger's scheduling function.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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